Provider Demographics
NPI:1588698559
Name:SOUTHPARK BEHAVIORAL MEDICINE SPECIALISTS, P.A.
Entity type:Organization
Organization Name:SOUTHPARK BEHAVIORAL MEDICINE SPECIALISTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-442-1655
Mailing Address - Street 1:6845 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3500
Mailing Address - Country:US
Mailing Address - Phone:704-442-1655
Mailing Address - Fax:704-442-9360
Practice Address - Street 1:6845 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3500
Practice Address - Country:US
Practice Address - Phone:704-442-1655
Practice Address - Fax:704-442-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93004262084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7917260Medicaid
NC7917260Medicaid
2343394Medicare ID - Type UnspecifiedINDIVIDUAL
B61506Medicare UPIN